Laser Therapy for Bladder Problems in Women

More than 50% of all women suffer from bladder weakness, incontinence or sudden urge to urinate during their lifetime, forcing them to visit a toilet. The quality of life is massively restricted as a result. The problems increase with age and are particularly pronounced during menopause. Even at a young age, a predisposition can lead to frequent bladder infections (cystitis), which are a frequent cause for antibiotic therapy until old age. The following bladder problems are distinguished:

  • Stress Urinary Incontinence (SUI) – defined as involuntary loss of urine during physical exertion or sneezing or coughing; is associated with an overactive bladder in up to 50%.
  • Overactive bladder (ÜAB, OAB = overactive bladder, urge symptomatology, urgency) – defined as urge to urinate with or without loss of urine, which may be manifested in
    • Imperative urination (sudden onset of a strong urge to urinate that is difficult to delay)
    • Pollakisuria (frequent urination with a low-filled bladder).
    • Nocturia (frequent nocturnal urination without underlying disease (eg, acute or chronic infections, neurogenic causes)).
  • Mixed Urinary Incontinence (MUI) – defined as the simultaneous occurrence of symptoms of urge incontinence and stress incontinence; patients lose urine during stress and at the same time suffer from a strong barely suppressible urge to urinate.

A detailed medical history is the first step in the clarification of bladder problems. In particular, the gynecological and obstetric history, relevant concomitant diseases and medications are important to develop a treatment plan. Validated questionnaires can be used to assess symptoms, severity, or impairment of quality of life [Guidelines 1, 2]. Micturition diaries are helpful in quantifying the frequency of urination during the day and night and recording incontinence episodes. For any new onset of incontinence, symptomatic urinary tract infection should be ruled out by urinalysis.

Treatment Options

Conservative treatment options are always the first step in therapy, according to the guidelines, and may vary depending on the cause and symptoms. For stress incontinence, pelvic floor exercises are the first-line therapy, combined with bladder training. Especially during pregnancy and after childbirth, pelvic floor training should be used to prevent incontinence. Often a contributing cause of stress incontinence is obesity. A weight reduction of more than 5% significantly improves the problem. Biofeedback, drug therapies and also pessary therapy (device that is inserted into the vagina) have a firm place in the treatment of stress incontinence. Medication may include duloxetine – a serotonin/norepinephrine reuptake inhibitor. It increases urethral closure by increasing activity of the pudendal nerve. Surgical therapy should be considered only after conservative options have been exhausted. Currently, surgical tape inserts that assist the urethral closure mechanism are preferred because they are successful in > 75% of cases. For overactive bladder, pelvic floor exercises and behavioral therapy are the first-line therapy. Medications include anticholinergics, mirabegron (ß3-mimetic) and botulinum toxin. Laser therapy for bladder problems

Unfortunately, current conservative therapy options such as pelvic floor exercises, electrical stimulation, and pessary therapy are often unsatisfactory and associated with low compliance. Drug therapy options are often discontinued due to side effects and lack of effectiveness. Surgical therapy is also unsatisfactory in many cases, not to mention complication rates. With innovative, breakthrough CO2 or Er:Yag laser therapy, there is a simple, non-invasive, highly effective way to treat all of the above problems. This is done by stimulating the body’s own regenerative mechanisms. Indications (areas of application)

  • Stress incontinence (stress incontinence).
  • Overactive bladder (OAB) with or without incontinence.
    • Imperative urge to urinate (Urgency, Drangymptomatik).
    • Pollakisuria (frequent urination with a low-filled bladder).
    • Nocturia (frequent nocturnal micturition without underlying disease (eg, acute or chronic infections, neurogenic causes)).

Contraindications

  • Acute inflammation
  • Premalignant (tissue alterations that are histopathologically predictive of malignant degeneration) or malignant (malignant) disease, respectively
  • Previous vaginal mesh surgery.

Before treatment

Before the start of treatment should be an educational and counseling discussion between the doctor and the patient. The content of the conversation should be the goals, expectations and the possibilities of treatment, as well as side effects and risks. Above all, there must be a detailed discussion of other therapeutic options, including previously performed therapies.

The procedure

The urethra (urethra), the sphincter of the bladder, and part of the floor of the bladder are in close proximity to the anterior vaginal wall/vaginal wall (distance a few millimeters). Therefore, laser application is possible through the vagina. After inserting a laser probe made slippery with baby oil, the vaginal skin is lasered at defined intervals, each 1 cm apart. There are two procedures:

  • Treatment of the entire vaginaLaser application by a spiral outward 360° rotary motion. This procedure is usually useful because in very many cases there is concomitant vulvovaginal atrophy with vaginal dryness and dyspareunia (pain during intercourse).
  • Treatment of the anterior vaginal wall (vaginal wall)Alternatively, some authors have described treatment of the anterior vaginal wall only, advancing the vaginal probe to the anterior vaginal vault of the vagina and then retracting the probe centimeter by centimeter.

The treatment takes about 5-10 minutes and is painless to almost painless. Occasionally, a small, not disturbing, heating and the feeling of urination is perceived. In terms of feeling, the application is similar to that of a vaginal ultrasound.

Mode of action

The mode of action in stress urinary incontinence (SUI) is not yet precisely known. It is assumed – in analogy to the effect in the lamina propria of the vagina (connective tissue layer of the vagina) – that laser treatment leads to an improvement of the urethral closure (urethral obstruction) through regeneration of the periurethral (“around the urethra“) tissue, i.e., through strengthening and tightening, as well as through fluid retention and improved blood supply to the connective tissue. As numerous studies have shown, this applies to both stress incontinence and overactive bladder function. The mode of action of lasers (erbium YAG laser, CO2 laser) used for urogynecologic indications is based on hyperthermia (overheating) and coagulation (coagulation of protein). Hyperthermia leads to tissue tightening and regeneration of epidermal and subepidermal structures by heating the tissue to 45-60 °C or by coagulation and ablation (laser vaporization) at 60-90 °C via activation of heat shock proteins and denaturation of collagen fibers and namely by:

  • Stimulation of the extracellular matrix (extracellular matrix, intercellular substance, ECM, ECM) in terms of nutrient uptake and fluid retention.
  • New formation of
    • Elastic and collagen fibers
    • Capillaries.

Depending on the energy setting, the focus is on the effect of hyperthermia or coagulation and ablation. Combined settings are possible. The wavelength of the CO2 laser is 10.6 µm, the Er:Yag laser is 2940 nm. Both are absorbed by the tissue water. That of the Erbium YAG laser is about 15 times higher than that of the CO2 laser. Fractional laser applications

In contrast to the ablative forms of laser therapy, in which the tissue is removed over a wide area and a wound area is created that is dependent on the size of the ablated area, fractionated therapy – only this is used in the urogynecological field – creates tiny pinprick-like micro-wounds with healthy skin areas in between. Since only about 20-40% of the treated area is lasered and the rest remains intact, there are few side effects and healing is rapid. The laser energy penetrates the epithelium and reaches the subepithelial tissue layer (vagina: lamina propria).The underlying fibromuscular skin layers are not reached, so they are spared. Depending on the laser energy, the maximum penetration depth is about 200-700 µm (0.2-0.7 mm). This ensures that surrounding tissue is not damaged. The targeted injury stimulates skin regeneration via the release of heat shock proteins and various growth factors (e.g. TGF-Beta). The result is the restoration of a healthy epithelium and underlying subepithelial layer, in the vagina the lamina propria, with normal function, including at the urethrovesical angle. Since the urethra is developmentally derived from the same tissue as the external genitalia and vagina, laser energy in the urethra, periurethral (“around the urethra”) tissue, and bladder floor suggests regeneration effects as in the vagina. Functional effects confirm this (see below under “Results”). The laser energy deposits fluid, water-binding glycoproteins and hyaluronic acid and stimulates the formation of collagen and elastic fibers. Especially important is the formation of new capillaries, which guarantees a long-term supply of oxygen and nutrients. Effect on stress incontinence

The cause of stress urinary incontinence (SUI) is a weakness of the connective tissue and muscles of the pelvic floor. The periurethral and paravaginal tissue is sustainably strengthened and consolidated by laser therapy. Anatomically and histologically, the vaginal walls thicken, providing improved blood flow and stability to the pelvic floor as well as the urethral sphincter and paraurethral tissues. The vagina regains its normal acidic pH, is elastic, stretchable and moist. During sexual arousal, fluid is squeezed out of the lamina propria, which ensures lubrication during intercourse. All these effects have been demonstrated microscopically and by controlled studies. Effect on overactive bladder

The pathophysiological causes of overactive bladder (ÜAB, OAB = Overactive Bladder) are complex. However, the degenerative changes due to childbirth and hormone deficiency in the pelvic floor area play an important role functionally. The therapy of overactive bladder has partly very different central and peripheral medicinal, behavioral therapeutic but also intravesical (“inside the bladder”) and neuromodulatory starting points. Intensive pelvic floor muscle training also leads to an improvement in symptoms. Physiologically, information of the bladder filling state is triggered by afferent nerve pathways of the pelvic floor, urethra, bladder wall, and urothelium (multilayered covering tissue (epithelium) of the urinary tract), which are disrupted by different mechanisms in OAB. It remains unclear whether the mechanism of action of the laser in OAB, as in stress incontinence, is positively influenced by strengthening the pelvic floor, possibly additionally by mechanical or chemical influence on the afferents, or by the combination. However, the positive effect is undisputed. Lin’s 3-D ultrasound studies show a decrease in bladder neck mobility, midurethral mobility, and echo-deficient areas of the entire urethra. They interpret this as laser-induced periurethral connective tissue changes associated with improvement in OAB symptoms.

Results

In 2012, Fistonic first reported on laser therapy for stress incontinence at the 15th Congress of the European Society for Sexual Medicine in Amsterdam. Since then, there have been many studies that have ensured the efficacy of laser therapy for stress incontinence, overactive bladder, and mixed forms [4, 11, 13, 15, 17-31]. Many studies were prospective non-randomized observational studies without control groups and some with small numbers of participants and a short follow-up period. Some of the study parameters varied widely. Results on the main objectifiable parameters were:

  • Validated symptomatology and quality of life questionnaires [guidelines 1, 2]: eg.
    • ICIQ-UI-SF (international consultation of incontinence questionnaire urinary incontinence short form) [ eg, 11, 18, 24, 27].
    • APFQ = Australian Pelvic Floor Questionnaire [21 (questions on SUI + OAB)]
    • Incontinence Impact Questionnaire Short Form (IIQ-7).
    • Urogenital Distress Inventory Short Form (UDI-6 and IID-7).
    • Overactive Bladder Symptom Score (OABSS)
  • Objectifiable parameters:
    • Pad test
    • urodynamic parameters:
      • Z. E.g., increase in urethral pressure.
    • Perineometry
    • Perineal ultrasound

Evaluations

  • Validated questionnaires
    • All surveys showed uniformly significant improvements in symptomatology, sexual function, and quality of life.
  • Objectifiable parameters
    • In the pad test, all tests showed significant improvements.
    • For urodynamic parameters, only two examinations showed different results (1 x ↑ , 1 x ±):
      • Khalafalla found significant improvement of urodynamic parameters six months after laser treatment (maximum urethral pressure (MUP), maximum urethral closure pressure (MUCP), functional urethral length (FUL), continence length (CL), urethral closure pressure area (UCPA), continence area (CA)).
      • Tien found no changes in urodynamic parameters with significant improvement in pad test.
    • In perineometry (measurement of the strength of contractions of the pelvic floor muscles), the results were different [2x ↑, two 1x ±):
      • Two studies showed significant improvement in pelvic floor muscle function.
      • Lin found no increase in pelvic floor muscle contractility, although perineal sonography clearly supported subjective improvement in SUI and OAB.
    • Perineal 3D ultrasound at six months revealed:
      • decrease in
        • Bladder neck mobility
        • Midurethral mobility
        • Echo-poor areas of the entire urethra.

      According to the interpretation of the authors, this indicates laser-induced changes in the bladder neck, urethra (urethra) and periurethral (“around the urethra”) connective tissue, which may lead to an improvement in incontinence problems (bladder weakness).

  • Biopsy/Histology
    • Bioptic examinations before and after laser therapy were performed in two papers: From the anterior vaginal wall and from the uretrovesical angle. Both works showed regeneration of the vaginal epithelium (epithelium, lamina propria) with significant increase in elastic and collagen fibers and capillary blood vessels.

Prospects of initial interesting studies

Results of randomized controlled trials

To date, there is only one randomized controlled trial of stress urinary incontinence (SUI). 114 premenopausal patients (about ten to fifteen years before menopause/time of last menstrual period) were randomized into a laser intervention group and a sham group. Validated questionnaires on urinary incontinence, quality of life or sexual function, perineometry (measurement of the strength of contractions of the pelvic floor muscles) and side effects were evaluated. For all validated questionnaires, there was a significant improvement in incontinence problems, sexual function, quality of life, and perineometry after completion of therapy in the laser group compared to the sham-treated control group, with no significant side effects, and good tolerability. Results of long-term studies

Currently, there are only three long-term studies whose follow-up was between 24 and 36 months after the end of laser therapy. González Isaza confirmed significant improvement of symptoms at 12, 24 and 36 months in 161 postmenopausal patients with mild stress urinary incontinence (SUI), 40% of whom were taking hormone replacement therapy, using ICIQ-SF values and the pad test. Gambacciani studied 205 postmenopausal patients primarily from the standpoint of vulvovaginal atrophy (changes in the skin of the vagina (vagina) and vulva (set of external primary sex organs) that can occur in women with declining estrogen levels). Among them were 114 female patients with urinary incontinence (bladder weakness). In these patients, the anterior vaginal wall (vaginal wall) was additionally treated with laser therapy. Using validated questionnaires (VHIS, ICIQ-UI SF), there was a significant improvement in both vaginal problems (vaginal problems) and SUI 12 months after completion of therapy.In follow-up examinations after 18 and 24 months, the positive effects slowly returned to baseline values. Of interest was a third group using local therapy (local estrogens or lubricants), whose symptom improvements were almost equivalent to those of laser therapy, but whose effects were no longer detectable after the end of therapy. Behnia-Willison studied 58 women, 45 of whom were postmenopausal (44 were receiving vaginal estrogen) with a positive cough test and hypermobility of the urethra on ultrasound. All were encouraged to continue topical estrogen therapy and pelvic floor exercises. Approximately 70% showed statistically significant improvement in quality of life, SUI and OAB symptoms (symptoms of stress incontinence and overactive bladder) 12 and 24 months after cessation of therapy. Results on comparative studies

  • OAB (overactive bladder): pharmacotherapy versus laser therapyOkui studied two drug therapy groups of patients suffering from OAB. The effects of anticholinergics (N=50) are compared with the ß3-mimetic mirabegron (N=50) and vaginal laser therapy (N=50). The medication regimen was followed for the entire observation period of one year. In contrast, laser therapy was discontinued after three applications at four-week intervals after three months. The final evaluation was made after one year.The use of the laser showed equivalent positive improvements in symptomatology even seven months after the last laser therapy. However, side effects were significantly lower and vaginal health also improved significantly, as shown by the VHIS score.
  • Comparison between surgery and laser therapy:In the comparison between TOT (transobturator tape), TVT (tension-free vaginal tape), and laser therapy, the pad and ICIQ-SF tests showed comparable therapeutic results. Laser therapy was clearly superior in the OABSS test and in complication rates.

Intraurethral laser applications.

Gaspar et al reported the use of an intraurethral erbium:Yag laser in two pilot studies. In the first study, 22 patients with SUI III, and in the second study, 29 patients (14= moderate,11= severe, 4= very severe HI) were treated with two applications of the laser. Three and six months after completion of therapy, they reported significant improvement in incontinence problems (difficulty holding urine). Tolerability was good, and the rate of side effects was low.

After treatment

After treatment, patients can immediately return to their usual lives. No special therapeutic measures are necessary. Moisturizing creams and other familiar local measures are possible. There should be no sexual intercourse for three to four days.

Possible complications

Side effects are minimal and usually last only 3-4 days.

  • Discharge minor (brown, pink, watery).
  • Sensitivity to touch
  • Dysuria (pain during urination)
  • Inflammation
  • Pruritus (itching)/edema (swelling)/redness
  • Spotting (rare)

Benefits of laser therapy

  • Virtually painless therapy
  • Without pretreatment
  • Without significant side effects
  • Without anesthesia
  • Without aftercare
  • Hormone-free
  • Outpatient (can be performed in a few minutes)

Critical evaluation

Currently often missing

  • Large and randomized trials
    • Compared to previous therapies
    • With long-term results
  • A comparison of the different laser systems
  • Uniform therapy regimen for laser therapy in the genital area.
    • Ablative
    • Thermal non-ablative
    • Ablative + thermal combined
  • Uniform dosages or dose-response relationships.

Resume

Despite many unanswered questions, laser therapy is a therapy with great prospects for the future, because the success rates are relatively high with good patient compliance and few side effects (see above “Benefits of therapy”), combined with a significantly improved quality of life (overall and sexual). After exhausting all therapeutic options recommended in the guidelines to date, it can already be offered today as a possible alternative or complementary therapy with the above-mentioned limitations.In stress incontinence (present when urine leaks involuntarily when coughing or sneezing), the offer can be discussed instead of surgery, especially from the point of view that the currently favored tapes are controversial because of long-term side effects. In overactive bladder syndrome (OAB), it can be discussed as a supplement or alternative because the efficacy is equally good, but the side effect rate is very low and occurs only briefly for a few days after application. Compliance problems, as they are repeatedly described in the conservative therapy of stress incontinence and overactive bladder (OAB) syndrome, do not occur with laser therapy.